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Statement of Intent to Pay Prevailing Wages Addendum A

Please use this addendum to list additional Crafts/Trades/Occupations when you need to add more Crafts/Trades/Occupations than the Statement of Intent to Pay Prevailing Wages form can accommodate. Addendum A is for form F700-029-000.



Formulario
F700-160-000
 
Statement of Intent to Pay Prevailing Wages Addendum C

Please use this addendum to provide any additional information you want to communicate to L&I when you file a Statement of Intent to Pay Prevailing Wages. Addendum C is for form F700-029-000.



Formulario
F700-163-000
 
Farm Internship Agreement

Agreement form: Prior to hiring an intern, farms that have received a Farm Intern Program certificate must complete this agreement with the intern and submit it to the department.



Formulario
F700-157-000
 
Application for Farm Internship

Application form: Small farm owners wishing to participate in the pilot small farm internship program must complete this form and submit it to the department. The information requested on the form is required to process an application for approval in order to issue a certificate of participation.



Formulario
F700-158-000
 
An Annual Electrical Permits Saves Time and Money. Would it Work for You?

Flier: Describes when facility operators/owners qualify for an annual electrical permit.



Publicaci贸n
F500-123-000
 
START Program (Safety through Achieving Recognition Together)
Fact sheet: Provides an overview of START, a program that recognizes occupational safety and health excellence in small businesses. Includes program requirements and benefits.

Publicaci贸n
F417-229-000
 
Pension and Survivor Benefits in Washington State's Workers' Compensation Program--English/Spanish (Beneficios de Pensión y para Sobrevivientes del Programa de Compensacin para Trabajadores de Washington)

Pamphlet/booket: Answers the most common questions about pension and survivor benefits under Washington's workers' compensation program.



Publicaci贸n
F242-352-909
 
L&I Chiropractic Consultant Application
This application is for doctors applying for second opinion examiner (consultant) status. Current consultants do not need to reapply.

Formulario
F245-393-000
 
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.
Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Formulario
F800-116-000
 
Electrical Telecommunication Principal Member Owner Update Request

Electrical Telecommunication Principal Member Owner Update Request



Formulario
F500-124-000
 
F245-392-000 Resource Utilization Group (RUG) Residential Care Services for L&I Injured Workers (In place of MDS 3.0 beginning October 1, 2010.)
Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.

Formulario
F245-392-000
 
Affidavit of Wages Paid EHB 2805 Addendum
F700-164-000 is an addendum to your Affidavit of Wages Paid Form. RCW 39.04.370 requires you to complete form F700-164-000 if the prime contract is at a cost of over one million dollars ($1,000,000). If you fail to properly provide the requested information more than one time between September 1, 2010 and December 31, 2013, pursuant to RCW 39.04.350(1)(f) you will not be considered a responsible bidder qualified to be awarded a public works project. Use as many of these forms as you need in order to provide the requested information for all relevant project items. This is an addendum to form F700-007-000.

Formulario
F700-164-000
 
Challenging Times Demand Our Best
Booklet: Describes how L&I is making changes, both big and small, to better serve our customers and operate efficiently. Three areas of focus are fighting fraud, putting customers first and cutting costs. Features stories about three customers L&I has helped.

Publicaci贸n
F101-095-000
 
Self-Insurer Accident Report (SIF-2)

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.



Formulario
F207-002-000
 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Formulario
F207-028-000
 
Stop Work Payroll Report
Stop Work Payroll Report

Formulario
F262-043-000
 
HCFA Proprietary Format Companion Guide
This guide details the HCFA proprietary format structure and provides information regarding electronic billing to the department via Provider Express Billing (PEB).

Formulario
F245-394-000
 
Sports Player Coverage Agreement

Used by a sports team or league and professional athlete (player) to declare that the player's work is principally localized in another state in accordance to the provisions of RCW 51.12.120 and WAC 296-17-32503.



Formulario
F212-242-000
 
Safety for Commercial Dive Teams
Fact sheet: Provides an overview of safety for commercial dive teams, summarizes the key requirements of commercial diving regulations (WAC 296-37), and includes contact information.

Publicaci贸n
F417-226-000
 
What Are Your Rights when You Work for a Farm Labor Contractor? (English/Spanish) / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?

Fact sheet: Provides an overview of rights workers have when they are employed by a farm labor contractor. Several topics are covered, including regular wages, workplace safety, and help if injured on the job.



Publicaci贸n
F700-067-000
 
Avoid Liability for Your Farm Labor Contractor's Unpaid Debits (English/Spanish) / Evite su Obligación por las Deudas no Pagadas de su Contratista de Trabajadores Agrícolas

Fact sheet: Explains how employers could be liable for unpaid workers' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.



Publicaci贸n
F700-154-909
 
Manufactured Home Installer Certification Tag Order form

Manufactured Home Installer Certification Tag Order form



Formulario
F622-077-000
 
Manufactured Home Installer's Monthly Certification Tag Report

Manufactured Home Installer's Monthly Certification Tag Report



Formulario
F622-078-000
 
Manufactured Home Installer Certification Tag Transfer Request form

Manufactured Home Installer Certification Tag Transfer Request form



Formulario
F622-079-000
 
Affidavit of Wages Paid Addendum D

Please use this addendum to provide the details of the Apprentices associated with your Affidavit of Wages of Paid. Addendum D is for form F700-007-000.



Formulario
F700-165-000
 
A Safe and Healthy Workplace Begins with You
Pamphlet: Provides an overview of employers' responsibilities for workplace safety and health in Washington State. Covers free L&I services, including workplace consultations, online training and prevention resources and required posters. Intended for new businesses or businesses hiring employees for the first time.

Publicaci贸n
F417-210-000
 
Permit Refund Request

A form to request a refund for an electrical work permit, elevator permit, or factory-assembled structure alteration permit.



Formulario
F621-105-000
 
Application for L.E.P. Compensation Medical

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Formulario
F242-208-000

Otro(s) idioma(s):
Ingl茅s/Espa帽ol
Espa帽ol
 
Application for L.E.P. Compensation Medical (Spanish) Solicitud para Compensación por Reducción de Ingresos (Médicos)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Formulario
F242-208-909

Otro(s) idioma(s):
Ingl茅s
Espa帽ol
 
F242-208-999 Application for LEP compensation medical - Spanish Solicitud para Compensación por Reducción de Ingresos (Médico)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Formulario
F242-208-999

Otro(s) idioma(s):
Ingl茅s
Ingl茅s/Espa帽ol
 
F242-209-000 APPLICATION FOR L.E.P. COMPENSATION VOC
Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Formulario
F242-209-000

Otro(s) idioma(s):
Ingl茅s/Espa帽ol
Espa帽ol
 
F242-209-909 Application for LEP Vocational English/Spanish Solicitud para Compensación por Reducción de Ingresos (Vocacional)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Formulario
F242-209-909

Otro(s) idioma(s):
Ingl茅s
Espa帽ol
 
F242-209-999 application for LEP - Voc Spanish -  Aplicación para Compensación por Reducción de Ingresos (Vocacional)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.



Formulario
F242-209-999

Otro(s) idioma(s):
Ingl茅s
Ingl茅s/Espa帽ol
 
Schedule of Future Payments for the Balance of the Permanent Partial Disability Award

Schedule of Future Payments for the Balance of the Permanent Partial Disability Award.



Formulario
F207-162-000
 
Vocational Technical Stakeholder Group (VTSG) Application
This form is for recruiting private sector vocational counselors to be on the Vocational Technical Stakeholder Group (VTSG). The form is made available on the department鈥檚 vocational website when recruiting for new members to assist the department in addressing vocational issues and formulating policy. Prospective applicants are expected to download, sign, and return the form to PSRS for consideration.

Formulario
F280-049-000
 
Minimum Header Structural Requirements for Manufactured Home Alterations

For use on sidewalls only. Maximum of one new opening up to 11-6 wide per sidewall. Edge of opening to be no closer than 4 from end of sidewall.



Formulario
F622-080-000
 
Account Deposit for Factory Assembled Structures Account Holders

You must have a contractor license number or have completed an application for a miscellaneous account to use this form.



Formulario
F622-081-000
 
FileFast postcard handout for workers
Handout (4.25 x 6): Explains to workers why and how to file an accident report online or by phone following an injury; also reminds them to stay in contact with employer and L&I.

Publicaci贸n
F242-398-000
 
FileFast poster for workers
Poster (8.5 x 11): Explains to workers why and how to file an accident report online or by phone following an injury and reminds them to stay in contact with employer and L&I.

Cartel
F242-399-000
 
FileFast wallet card for workers
Wallet card (3.5 x 2): Reminds workers of FileFast web address and number for call center.

Publicaci贸n
F242-400-000
 
Faulty Water Heaters and Kids Don't Mix
Fact sheet: Designed for operators of childcare facilities, this fact sheet explains the importance of keeping boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency, and fees.

Publicaci贸n
F620-059-000
 
Five Steps to File
Flyer: Reviews the steps for filing workers' compensation quarterly reports online and lists the filing due dates.

Publicaci贸n
F212-243-000
 
ASC X12N 005010 EDI Transactions Companion Guide
Description: This guide details the HIPAA ASC X12N 005010 format structure for EDI and provides information regarding electronic billing To the department via Provider Express Billing (PEB)

Manual
F245-398-000
 
The DOSH Consultation Manual

The DOSH Consultation Manual provides guidance regarding some of the internal operations of L&I and the Division of Occupational Safety and Health (DOSH). The contents of the manuals are not enforceable by any person or entity against the Department of Labor and Industries or the State of Washington.



Manual
F414-151-000
 
Your Premium Dollars at Work (2011)

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries.



Publicaci贸n
F200-019-000
 
Strategic Plan
Booklet: Explains the strategic direction of the Department of Labor & Industries. Includes a message from the director, goals, objectives and strategies.

Publicaci贸n
F101-099-000
 
Sawmillis & Woodworking Operations WAC 296-78

The Department of Labor and Industries has rewritten and reorganized for clarity and ease of use, Chapter 296-78 WAC, Sawmills and Woodworking Operations.



Manual
F414-010-000
 
Stay at Work Wage Reimbursement Application for Employers

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.



Formulario
F243-001-000
 
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.

Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000.



Formulario
F243-003-000
 
Safety Standards for Forklifts and Other Powered Industrial Trucks WAC 296-863

This chapter applies to powered industrial trucks, electric motors or internal combustion engines, fork trucks, forklifts, tractors, platform lift trucks, motorized hand trucks and other specialized industrial trucks.



Manual
F414-126-000
 
Complete Stay at Work Guide for Employers, The

Booklet: Explains Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Provides information on reimbursements, what is covered and how to apply. Detailed Q&A section included.



Publicaci贸n
F243-005-000
 
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.



Publicaci贸n
F243-006-000

Otro(s) idioma(s):
Espa帽ol
 
Settling your L&I claim might be right for you: A new option for injured workers over 55

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.



Publicaci贸n
F240-003-000

Otro(s) idioma(s):
Espa帽ol
 
Settling your injured worker's L&I claim: A new option for injured workers over 55

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is employers covered by the state's workers' compensation program. Self-insured employers should read Publication F240-005-000.



Publicaci贸n
F240-004-000
 
Safety Standards for Construction Work WAC 296-155

Construction work shall mean and include all or any part of excavation, construction, erection, alteration, repair, demolition, and dismantling, of buildings and other structures.



Manual
F414-033-000
 
Provider Network Agreement
The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.

Formulario
F245-397-000
 
Self-Insurance Continuing Education Application for Course Approval and Attendance

Used by Certified Claims Administrators to apply for continuing education credits for a course attended that has not been approved for credits.



Formulario
F207-206-000
 
Safety Standards for Administrative Rules WAC 296-900

Administrative Rules and the DOSH Administrative Manual affords employers the right to administrative and judicial review of alleged violations, initial penalties and abatement periods.



Manual
F414-136-000
 
Safety Standards for Logging Operations WAC 296-54

This chapter establishes safety practices for all types of logging, log road construction and other forest activities using logging machinery and/or power saws regardless of the end use of the wood. This includes; logging, cutting and transporting timber, cutting timber, log harvesting logging, pulpwood logging camps, rails, rough wood, manufacturing, stump removing in the field, timber piling, timber pole cutting, tree chipping in the field, wood chipping in the field. In addition, logging and personal protective equipment, hand and portable powered tools, falling and bucking, tree pulling, mechanized falling, climbing equipment, rigging, spars, wire rope and various types of cable logging systems, guylines, tail/lift trees and anchors, yarding, skidding, landing, transportation of logs and stationary trailer loaders, log unloading, booms, and rafting grounds, transportation crews, signals and signal systems.



Manual
F414-016-000
 
Provider Application and Notice for new firms

Complete this application and the StateWide Payee W-9 if you are applying for a firm Provider Number with L&I.



Formulario
F252-088-000
 
OJT Accountability Agreement - Spanish Acuerdo de Responsabilidad de la Capacitación Durante el Transcurso del Trabajo

OJT Accountability Agreement in Spanish



Formulario
F280-029-999

Otro(s) idioma(s):
Ingl茅s
 
Scaffolds WAC 296-874

Scaffolds, Chapter 296-874 WAC, applies to suspended and supported scaffolds, including their supporting structure and anchorage points. A scaffold is a temporary elevated platform, including its supporting structure and anchorage points, used for supporting employees or materials. A suspended scaffold is one or more platforms suspended from an overhead structure by ropes or other non-rigid means.



Manual
F414-128-000
 
OJT Information Request and Recommendation form

VRCs can use this form to request information on a specific on -the -job (OJT) training opportunity listed on L&I's website, or to recommend an OJT training opportunity.



Formulario
F280-032-000
 
On-The-Job Training (OJT) Worksheet for Vocational Providers

On-The-Job Training (OJT) Worksheet for Vocational Providers



Formulario
F280-039-000
 
Chapter 296-842 WAC - Safety Standards - Respirators

An apparatus worn over the mouth and nose or the entire face to prevent the inhalation of dust, smoke, or other noxious substances. Respirator is a type of personal protective equipment designed to protect the wearer from airborne contaminants, oxygen deficiency, or both.



Manual
F414-119-000
 
On-the-Job Training Agreement Card
This card is used by an OJT Apprenticeship program ONLY. To receive this form, you must contact the Apprenticeship Section.

Formulario
F100-019-000
 
Related Supplemental Instruction Hours

Used by Apprenticeship programs to submit related instruction hours to L&I Apprenticeship section. It is preferred that programs use the combined RSI/OJT reporting form. RSI Hours must be reported quarterly.



Formulario
F100-228-000
 
Accountability Agreement

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have. For OJT retraining plans, please refer to form F280-029-000.



Formulario
F280-016-000

Otro(s) idioma(s):
Espa帽ol
 
Settling your L&I claim might be right for you: A new option for injured workers over 55 - Spanish (Llegar a un acuerdo sobre su reclamo de L&I puede ser lo correcto para usted - Una nueva opción para los trabajadores lesionados que tienen más de 55 años de edad)

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.



Publicaci贸n
F240-003-999

Otro(s) idioma(s):
Ingl茅s
 
On the Job Training Accountability Agreement

This form is for OJT training plans, and must be signed by the worker and VRC then sent in along with your training plan to L&I for approval. For non-OJT retraining plans, please refer to form F280-016-000.



Formulario
F280-029-000

Otro(s) idioma(s):
Espa帽ol
 
Q&A: Stay of Abatement Date

Fact sheet: Explains how an employer requests a "stay of abatement date." Effective July 1, 2012, an employer must fix a hazard cited in a workplace inspection during appeal unless he or she has requested and been granted a stay of abatement date.



Publicaci贸n
F417-235-000
 
On-The-Job Training Work Hours

Used to report the work hours for an on-the-job training employee.



Formulario
F100-229-000
 
Congratulations! You've been approved to hire minors
Card: Reminds employers of special work rules for employees under age 18. Lists key points and provides a Web address for where to find more detailed information. Sent to all employers who obtain a minor work permit endorsement on the master business license.

Publicaci贸n
F700-136-000
 
Intent to Hire Preferred Worker
Used by employers when hiring a preferred worker. This form must be received within 60 days of the hiring and the Preferred Worker Employer's Job Description (F280-022-000) form must be attached.

Formulario
F280-010-000
 
Using Apprentices on Public Works and Other Projects
Pamphlet: Provides a quick overview of the rules for using apprentices on public works projects, including apprentice utilization. Also describes the benefits of apprenticeship and where to get more information.

Publicaci贸n
F100-529-000
 
Inservice Inspection checklist
Inservice Inspection checklist for power boilers, low pressure boilers, pressure vessels, and hot water boilers.

Formulario
F620-060-000
 





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